Unlike what you see on TV, people who deal with emergencies
or the critically ill don’t stop to emote about what they just saw or did. We can’t. We wouldn't last if we stopped to think about it.
We have to take the incident, strip it of the lessons learned to store
them, and then stick the rest of the memory in a box. The box gets locked and shoved to the back of
our minds. Then we move on to the next
patient, quickly, because they likely don’t have spare time for us to “get it
together.”
I saw a picture online recently (it can be found here). It was pretty moving and dredged up some old thoughts. The picture is of an emergency physician who,
after a particularly bad death, walked out of the ED, knelt down and
cried. The picture was snapped by a
paramedic in his squad and, with permission, he posted
it online. The picture went viral,
especially in the emergency community, because we’ve all been there. We’ve all had experiences with the death of
babies or children or little old ladies who remind us of our grandmother or
whatever. Something about that patient
flips a switch, prevents our normal coping mechanisms from working and ruthlessly
guts us. We grieve, quietly, privately,
then the memory gets stuck in the box, we recompose and get back to work.
These incidents are rare, but they do happen (and if they
aren’t rare for a person, that person will be gone from their profession
quickly). But what happens more often
than the “gutted-grieve-get back in the saddle” events are moments of sadness.
Most of my moments of sadness came from my time working for
private ambulance services in Toledo and Cincinnati, where the bulk of our runs
were to nursing homes. I transported
countless people to the hospital when it was apparent this would be their last
trip. Most were so sick that they weren’t
aware of what was going on, but more than a few were just as aware of their
situation as I was, probably more so. I
learned early on that for these people the most effective therapy in my drug
box, airway kit, the cabinets of my one hundred thousand dollar squad and my
personal bag of tricks was simply to hold their hand. For many of them, mine was the last hand they
would hold, their last touch of humanity before entering the fast-paced,
overworked clinical realm of the emergency department. It always made me sad.
But something always made me sadder. The sadness was strong but brief. It was the sadness of bearing witness to permanent loss. The permanent loss was always heralded by a
physician who would speak what I consider to be the most powerful words: “Stop
CPR. Time of death is…”
In that instant,
that patient, that person, was gone forever.
All their knowledge and their experiences, their loves and losses,
memories good and bad, tragedies and triumphs, an older person’s accumulated
wisdom, a young person’s future and potential…poof. Gone.
I know that I did a bad job of concealing my sadness in that
moment. Frequently, a physician or a
nurse would see me and try to console me.
“It was her time,” they’d say. Or
“You did everything you could.” They
mistook my sadness as being a result of being defeated by our common
arch-nemesis, death.
That wasn’t the case at all.
I rarely placed any hope in saving these nursing home residents. They tended to be either chronologically
advanced, from their mid-80s to mid-90s, or ravaged by time and disease, with
65-year olds looking like centenarians and being just as fragile. We were crushing their chests with CPR,
inserting artificial airways, plying them with a dozen medications and blasting
their hearts with strong doses of electricity.
We worked by the book and everybody got our A-Game, but I harbored
no illusion of the outcome. Resuscitation was started on these folks because of a perverse
1980s federal rule regarding the number of deaths allowed in a nursing home,
and because the concept of Do Not Resuscitate orders and advanced directives
was still taking hold (because of this I have probably done more field
resuscitations than most EMS personnel today who weren’t around in the 80s).
Obviously futile effort or not, the sadness overtook me
whenever the physician said the most powerful words. Stop
CPR. Time of death is…
One day we transported a little old lady, whose weight and
age were approximately the same, to an ED while doing brutal and pointless CPR
on her. As we wheeled into the
resuscitation room we began to give verbal report to the assembling ED staff:
“87-year old female, down for unknown length of time before nursing home staff
found her. CPR in progress for
approximately 20 minutes.”
As we transferred her from our stretcher to their bed the
doc asked how far along we were in the resuscitation. We told him we gave the fourth dose of
epinephrine as we pulled in. That told
him everything he needed to know.
“Stop CPR. Time of death is…”
As I pulled my gloves off and headed to the sink to wash my
hands, I glanced over my shoulder at the body.
The sadness of permanent loss set in.
As usual, I didn’t hide it well and a nurse noticed.
“There wasn’t anything you could do for her,” she said
gently.
“I know. It’s just sad,” I said. I pointed at my head,
“Everything she had up here…everything she was is gone.”
She stared at me for a second, looked to the body and back
at me. I could see in her eyes she felt
it, too.
By the time I finished washing my hands the sadness had
passed. I had pushed it into the box and headed out to clean and restock the
squad, making it ready for our next adventure.
For decades I thought that other than that one nurse, I was
the only one who was so deeply affected by the most powerful words. It turns out I was wrong. It turns out that most, if not all of us,
have that feeling.
In February 2014, a nurse from Charlottesville, VA, named
Jonathan Bartels published an article in the journal Critical Care Nurse. In it
he describes “The Pause,” a sort of brief and quiet ceremony that begins right
after the most powerful words are said.
In Bartels’ words:
After a death in the emergency
department, I would stand, ask that no one leave, and invite my peers to bear
witness with me, to be together and present in a singular moment of grief and
loss. I would ask each to, in their own way, offer silent recognition of the
lost human life—someone’s mother, father, sibling, or child—to remember that
the person who had died loved and was loved, to understand that the person’s
passing deserved recognition, and to acknowledge that our own efforts, too,
were worthy of honor.
Even though it started out that way, The Pause isn’t just a
little local ritual. It caught on at his
hospital and is now part of the curriculum of the nursing program at the
University of Virginia and others. Word
of The Pause is spreading: I heard about it through a story on NPR.
While I may have practiced my own personal mini-version of
The Pause, I’m glad that Bartels had the courage to speak up and do the first
one openly. I’m sure that for many
people it will help blunt the power of the most powerful words.
